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Connolly T, Paxton K, McNair B. Timing of stroke survivors' hospital readmissions to guide APRNs in primary care. J Am Assoc Nurse Pract 2024; 36:416-423. [PMID: 39079094 DOI: 10.1097/jxx.0000000000000984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 11/21/2023] [Indexed: 09/17/2024]
Abstract
BACKGROUND Caring for patients after a neurovascular incident is common for advanced practice registered nurses (APRNs). Most neurological readmission studies focus on a small subset of neurovascular incident groups, but advanced practice nurses in primary care attend to a diverse neurovascular population and lack time to adequately search hospital records. PURPOSE The aim of this study was to determine readmission risk factors after a neurovascular incident to guide APRNs in the primary care setting. METHODOLOGY The study is a retrospective observational study that used a crude single predictor model to determine potential risks for readmission. RESULTS A total of 876 neurovascular participants were studied. Of these, only 317 experienced at least one hospital readmission, with 703 readmissions within 1 year, indicating some were readmitted more than once. Risks for readmission varied across neurovascular events. The main reasons for readmission were because of neurological, cardiovascular, and musculoskeletal complications. CONCLUSIONS Stroke readmission rates are high and require intervention by APRNs. To prevent readmission includes timely follow-up within 30 days and should also include longitudinal follow-up beyond 90 days to prevent hospital readmission. IMPLICATIONS Future studies are needed to create guidelines for APRNs that implement rehabilitation strategies to decrease hospital readmission for the neurovascular population that focus on interdisciplinary communication.
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Affiliation(s)
- Teresa Connolly
- College of Nursing, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kim Paxton
- College of Nursing, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Bryan McNair
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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2
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Magagnin AB, da Silva KL, Melo GZDS, Heidemann ITSB. Primary Health Care in transitional care of people with stroke. Rev Bras Enferm 2024; 77:e20230468. [PMID: 39082551 PMCID: PMC11290722 DOI: 10.1590/0034-7167-2024-0468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 04/12/2024] [Indexed: 08/02/2024] Open
Abstract
OBJECTIVES to understand the role of Primary Health Care teams in caring for people with stroke after hospital discharge. METHODS single case study, with integrated units of analysis, with a qualitative approach. Data triangulation occurred through interviews with professionals and family caregivers involved in transition of care, in addition to direct observations in rounds and document analysis. For the analyses, the analytical strategies of theoretical propositions and construction of explanations were used, with the help of ATLAS.ti®. RESULTS the importance of counter-referral, the role of community health workers and the multidisciplinary team, health promotion, secondary prevention, home visits as a visceral attribute and nurses as care managers are evident. FINAL CONSIDERATIONS the high demand on teams and the Social Determinants of Health interfere with adequate continuity of care. Transitional care programs that enable continuity of care are recommended.
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Jones Berkeley SB, Johnson AM, Mormer ER, Ressel K, Pastva AM, Wen F, Patterson CG, Duncan PW, Bushnell CD, Zhang S, Freburger JK. Referral to Community-Based Rehabilitation Following Acute Stroke: Findings From the COMPASS Pragmatic Trial. Circ Cardiovasc Qual Outcomes 2024; 17:e010026. [PMID: 38189125 PMCID: PMC10997162 DOI: 10.1161/circoutcomes.123.010026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 10/13/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Few studies on care transitions following acute stroke have evaluated whether referral to community-based rehabilitation occurred as part of discharge planning. Our objectives were to describe the extent to which patients discharged home were referred to community-based rehabilitation and identify the patient, hospital, and community-level predictors of referral. METHODS We examined data from 40 North Carolina hospitals that participated in the COMPASS (Comprehensive Post-Acute Stroke Services) cluster-randomized trial. Participants included adults discharged home following stroke or transient ischemic attack (N=10 702). In this observational analysis, COMPASS data were supplemented with hospital-level and county-level data from various sources. The primary outcome was referral to community-based rehabilitation (physical, occupational, or speech therapy) at discharge. Predictor variables included patient (demographic, stroke-related, medical history), hospital (structure, process), and community (therapist supply) measures. We used generalized linear mixed models with a hospital random effect and hierarchical backward model selection procedures to identify predictors of therapy referral. RESULTS Approximately, one-third (36%) of stroke survivors (mean age, 66.8 [SD, 14.0] years; 49% female, 72% White race) were referred to community-based rehabilitation. Rates of referral to physical, occupational, and speech therapists were 31%, 18%, and 10%, respectively. Referral rates by hospital ranged from 3% to 78% with a median of 35%. Patient-level predictors included higher stroke severity, presence of medical comorbidities, and older age. Female sex (odds ratio, 1.24 [95% CI, 1.12-1.38]), non-White race (2.20 [2.01-2.44]), and having Medicare insurance (1.12 [1.02-1.23]) were also predictors of referral. Referral was higher for patients living in counties with greater physical therapist supply. Much of the variation in referral across hospitals remained unexplained. CONCLUSIONS One-third of stroke survivors were referred to community-based rehabilitation. Patient-level factors predominated as predictors. Variation across hospitals was notable and presents an opportunity for further evaluation and possible targets for improved poststroke rehabilitative care. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02588664.
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Affiliation(s)
- Sara B Jones Berkeley
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health (S.B.J.B., A.M.J., F.W., S.Z.)
| | - Anna M Johnson
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health (S.B.J.B., A.M.J., F.W., S.Z.)
| | - Elizabeth R Mormer
- Department of Physical Therapy, University of Pittsburgh, School of Health and Rehabilitation Sciences (E.R.M., K.R., C.G.P., J.K.F.)
| | - Kristin Ressel
- Department of Physical Therapy, University of Pittsburgh, School of Health and Rehabilitation Sciences (E.R.M., K.R., C.G.P., J.K.F.)
| | - Amy M Pastva
- Department of Orthopaedic Surgery, Doctor of Physical Therapy Division and Center for the Study of Aging and Human Development, Duke University School of Medicine (A.M.P.)
| | - Fang Wen
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health (S.B.J.B., A.M.J., F.W., S.Z.)
| | - Charity G Patterson
- Department of Physical Therapy, University of Pittsburgh, School of Health and Rehabilitation Sciences (E.R.M., K.R., C.G.P., J.K.F.)
- Department of Neurology, Wake Forest School of Medicine (P.W.D., C.D.B.)
| | - Pamela W Duncan
- Department of Neurology, Wake Forest School of Medicine (P.W.D., C.D.B.)
| | | | - Shuqi Zhang
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health (S.B.J.B., A.M.J., F.W., S.Z.)
| | - Janet K Freburger
- Department of Physical Therapy, University of Pittsburgh, School of Health and Rehabilitation Sciences (E.R.M., K.R., C.G.P., J.K.F.)
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4
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Hou Y, D'Souza K, Kucharska-Newton AM, Freburger JK, Bushnell CD, Halladay JR, Duncan PW, Trogdon JG. Postacute Expenditures Among Patients Discharged Home After Stroke or Transient Ischemic Attack: The COMprehensive Post-Acute Stroke Services (COMPASS) Trial. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1453-1460. [PMID: 37422076 DOI: 10.1016/j.jval.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 05/23/2023] [Accepted: 06/14/2023] [Indexed: 07/10/2023]
Abstract
OBJECTIVES The COMPASS (COMprehensive Post-Acute Stroke Services) pragmatic trial cluster-randomized 40 hospitals in North Carolina to the COMPASS transitional care (TC) postacute care intervention or usual care. We estimated the difference in healthcare expenditures postdischarge for patients enrolled in the COMPASS-TC model of care compared with usual care. METHODS We linked data for patients with stroke or transient ischemic attack enrolled in the COMPASS trial with administrative claims from Medicare fee-for-service (n = 2262), Medicaid (n = 341), and a large private insurer (n = 234). The primary outcome was 90-day total expenditures, analyzed separately by payer. Secondary outcomes were total expenditures 30- and 365-days postdischarge and, among Medicare beneficiaries, expenditures by point of service. In addition to intent-to-treat analysis, we conducted a per-protocol analysis to compare Medicare patients who received the intervention with those who did not, using randomization status as an instrumental variable. RESULTS We found no statistically significant difference in total 90-day postacute expenditures between intervention and usual care; the results were consistent across payers. Medicare beneficiaries enrolled in the COMPASS intervention arm had higher 90-day hospital readmission expenditures ($682, 95% CI $60-$1305), 30-day emergency department expenditures ($132, 95% CI $13-$252), and 30-day ambulatory care expenditures ($67, 95% CI $38-$96) compared with usual care. The per-protocol analysis did not yield a significant difference in 90-day postacute care expenditures for Medicare COMPASS patients. CONCLUSIONS The COMPASS-TC model did not significantly change patients' total healthcare expenditures for up to 1 year postdischarge.
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Affiliation(s)
- Yucheng Hou
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Karishma D'Souza
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anna M Kucharska-Newton
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Janet K Freburger
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Cheryl D Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Jacqueline R Halladay
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Pamela W Duncan
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Eliassen M, Arntzen C, Nikolaisen M, Gramstad A. Rehabilitation models that support transitions from hospital to home for people with acquired brain injury (ABI): a scoping review. BMC Health Serv Res 2023; 23:814. [PMID: 37525270 PMCID: PMC10388520 DOI: 10.1186/s12913-023-09793-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 07/07/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Research shows a lack of continuity in service provision during the transition from hospital to home for people with acquired brain injuries (ABI). There is a need to gather and synthesize knowledge about services that can support strategies for more standardized referral and services supporting this critical transition phase for patients with ABI. We aimed to identify how rehabilitation models that support the transition phase from hospital to home for these patients are described in the research literature and to discuss the content of these models. METHODS We based our review on the "Arksey and O`Malley framework" for scoping reviews. The review considered all study designs, including qualitative and quantitative methodologies. We extracted data of service model descriptions and presented the results in a narrative summary. RESULTS A total of 3975 studies were reviewed, and 73 were included. Five categories were identified: (1) multidisciplinary home-based teams, (2) key coordinators, (3) trained family caregivers or lay health workers, (4) predischarge planning, and (5) self-management programs. In general, the studies lack in-depth professional and contextual descriptions. CONCLUSIONS There is a wide variety of rehabilitation models that support the transition phase from hospital to home for people with ABI. The variety may indicate a lack of consensus of best practices. However, it may also reflect contextual adaptations. This study indicates that health care service research lacks robust and thorough descriptions of contextual features, which may limit the feasibility and transferability to diverse contexts.
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Affiliation(s)
- Marianne Eliassen
- Department of Health and Care Sciences, University of Tromsø, The Artic University of Norway, Tromsø, 9037, Norway.
| | - Cathrine Arntzen
- Department of Health and Care Sciences, University of Tromsø, The Artic University of Norway, Tromsø, 9037, Norway
- Center for Care Sciences, North, University of Tromsø, The Artic University of Norway, Tromsø, 9037, Norway
| | - Morten Nikolaisen
- Department of Health and Care Sciences, University of Tromsø, The Artic University of Norway, Tromsø, 9037, Norway
- Center for Care Sciences, North, University of Tromsø, The Artic University of Norway, Tromsø, 9037, Norway
| | - Astrid Gramstad
- Department of Health and Care Sciences, University of Tromsø, The Artic University of Norway, Tromsø, 9037, Norway
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Levoy K, Rivera E, McHugh M, Hanlon A, Hirschman K, Naylor M. Caregiver Engagement Enhances Outcomes Among Randomized Control Trials of Transitional Care Interventions: A Systematic Review and Meta-analysis. Med Care 2022; 60:519-529. [PMID: 35679175 PMCID: PMC9202479 DOI: 10.1097/mlr.0000000000001728] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Fluctuations in health among chronically ill adults result in frequent health care transitions. Some interventions to improve patient outcomes after hospitalization include caregiver engagement as a core component, yet there is unclear evidence of the effects of this component on outcomes. OBJECTIVE The objective of this study was to synthesize evidence regarding the attention given to caregiver engagement in randomized control trials of transitional care interventions (TCIs), estimate the overall intervention effects, and assess caregiver engagement as a moderator of intervention effects. METHODS Three databases were systematically searched for randomized control trials of TCIs targeting adults living with physical or emotional chronic diseases. For the meta-analysis, overall effects were computed using the relative risk (RR) effect size and inverse variance weighting. RESULTS Fifty-four studies met criteria, representing 31,291 participants and 66 rehospitalizations effect sizes. Half (51%) the interventions lacked focus on caregiver engagement. The overall effect of TCIs on all-cause rehospitalizations was nonsignificant at 1 month (P=0.107, k=29), but significant at ≥2 months [RR=0.89; 95% confidence interval (CI): 0.82, 0.97; P=0.007, k=27]. Caregiver engagement moderated intervention effects (P=0.05), where interventions with caregiver engagement reduced rehospitalizations (RR=0.83; 95% CI: 0.75, 0.92; P=0.001), and those without, did not (RR=0.97; 95% CI: 0.87, 1.08; P=0.550). Interventions with and without caregiver engagement did not differ in the average number of components utilized, however, interventions with caregiver engagement more commonly employed baseline needs assessments (P=0.032), discharge planning (P=0.006), and service coordination (P=0.035). DISCUSSION Future TCIs must consistently incorporate the active participation of caregivers in design, delivery, and evaluation.
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Affiliation(s)
- Kristin Levoy
- Department of Community and Health Systems, Indiana University (IU) School of Nursing, 600 Barnhill Dr., Indianapolis, IN 46202
- IU Center for Aging Research, Regenstrief Institute, 1101 W. 10 St., Indianapolis, IN 46202
| | - Eleanor Rivera
- University of Illinois Chicago College of Nursing, 845 S. Damen Ave, Chicago, IL 60612
| | - Molly McHugh
- NewCourtland Center for Transitions and Health, Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, 3615 Chestnut Street, Ralston-Penn Center, Philadelphia, PA 19104
| | - Alexandra Hanlon
- Center for Biostatistics and Health Data Science, Department of Statistics, College of Science, Virginia Tech, 4 Riverside Circle, Roanoke, VA 24016
| | - Karen Hirschman
- NewCourtland Center for Transitions and Health, Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, 3615 Chestnut Street, Ralston-Penn Center, Philadelphia, PA 19104
| | - Mary Naylor
- NewCourtland Center for Transitions and Health, Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, 3615 Chestnut Street, Ralston-Penn Center, Philadelphia, PA 19104
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7
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Jee S, Jeong M, Paik NJ, Kim WS, Shin YI, Ko SH, Kwon IS, Choi BM, Jung Y, Chang W, Sohn MK. Early Supported Discharge and Transitional Care Management After Stroke: A Systematic Review and Meta-Analysis. Front Neurol 2022; 13:755316. [PMID: 35370909 PMCID: PMC8965290 DOI: 10.3389/fneur.2022.755316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 02/16/2022] [Indexed: 11/30/2022] Open
Abstract
Objective To investigate the available evidence on early supported discharge (ESD) and transitional care (TC) delivery service in patients with cerebrovascular disease. Methods A systematic literature search was conducted to collect all available evidence on the use of ESD and TC services. We included cluster-randomized pragmatic trials or randomized controlled trials (RCTs) that recruited patients with stroke or transient ischemic attack to receive either conventional care or any care service intervention that included rehabilitation or support provided by professional medical personnel with the aim of accelerating and supporting home discharge. Relevant data were electronically searched through international databases (Cochrane Library, EMBASE, and PubMed) and incorporated into a summary grid to investigate research outcomes and provide a narrative synthesis. Furthermore, we compared the outcomes in terms of length of hospital stay, patient and caregiver outcomes, and mortality through meta-analysis. Results We identified and included a total of 20 publications of various original randomized studies. There were 18 studies conducted in western countries and 2 in eastern countries. The meta-analysis revealed a tendency that ESD or TC could decrease the length of hospital stay more than the usual care [standardized mean difference (SMD) -0.13; 95% confidence interval (CI) -0.31 to 0.04 days; P = 0.14]. Moreover, there was a tendency that ESD resulted in better activities of daily living (ADL) than usual care (SMD 0.29; 95% CI -0.04 to 0.61; P = 0.08). Patient outcome based on modified Rankin scale (mRS) score (SMD -0.11; 95% CI -0.38 to 0.17; P = 0.45] and mortality (odds ratio 0.80; 95% CI 0.56-1.17; P = 0.25) did not reveal any significant difference. The Caregiver Strain Index revealed no difference. Conclusion We did not find a large effect size for the use of TC and ESD. When implementing the TC and ESD model from western to Asian countries, services should be prepared and implemented in accordance with national medical rehabilitation pathways for cerebrovascular disease.
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Affiliation(s)
- Sungju Jee
- Department of Rehabilitation Medicine, Chungnam National University Hospital and Chungnam National University College of Medicine, Daejeon, South Korea
| | - Minah Jeong
- Department of Rehabilitation Medicine, Chungnam National University Hospital and Chungnam National University College of Medicine, Daejeon, South Korea
| | - Nam-Jong Paik
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Won-Seok Kim
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Yong-Il Shin
- Department of Rehabilitation Medicine, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Pusan, South Korea
| | - Sung-Hwa Ko
- Department of Rehabilitation Medicine, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Pusan, South Korea
| | - In Sun Kwon
- Clinical Trials Center, Chungnam National University Hospital, Daejeon, South Korea
| | - Bo Mi Choi
- Department of Public Health and Medical Services, Chungnam National University Hospital, Daejeon, South Korea
| | - Yunsun Jung
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Wonkee Chang
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Min Kyun Sohn
- Department of Rehabilitation Medicine, Chungnam National University Hospital and Chungnam National University College of Medicine, Daejeon, South Korea
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Bushnell CD, Kucharska-Newton AM, Jones SB, Psioda MA, Johnson AM, Daras LC, Halladay JR, Prvu Bettger J, Freburger JK, Gesell SB, Coleman SW, Sissine ME, Wen F, Hunt GP, Rosamond WD, Duncan PW. Hospital Readmissions and Mortality Among Fee-for-Service Medicare Patients With Minor Stroke or Transient Ischemic Attack: Findings From the COMPASS Cluster-Randomized Pragmatic Trial. J Am Heart Assoc 2021; 10:e023394. [PMID: 34730000 PMCID: PMC9075395 DOI: 10.1161/jaha.121.023394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Mortality and hospital readmission rates may reflect the quality of acute and postacute stroke care. Our aim was to investigate if, compared with usual care (UC), the COMPASS-TC (Comprehensive Post-Acute Stroke Services Transitional Care) intervention (INV) resulted in lower all-cause and stroke-specific readmissions and mortality among patients with minor stroke and transient ischemic attack discharged from 40 diverse North Carolina hospitals from 2016 to 2018. Methods and Results Using Medicare fee-for-service claims linked with COMPASS cluster-randomized trial data, we performed intention-to-treat analyses for 30-day, 90-day, and 1-year unplanned all-cause and stroke-specific readmissions and all-cause mortality between INV and UC groups, with 90-day unplanned all-cause readmissions as the primary outcome. Effect estimates were determined via mixed logistic or Cox proportional hazards regression models adjusted for age, sex, race, stroke severity, stroke diagnosis, and documented history of stroke. The final analysis cohort included 1069 INV and 1193 UC patients (median age 74 years, 80% White, 52% women, 40% with transient ischemic attack) with median length of hospital stay of 2 days. The risk of unplanned all-cause readmission was similar between INV versus UC at 30 (9.9% versus 8.7%) and 90 days (19.9% versus 18.9%), respectively. No significant differences between randomization groups were seen in 1-year all-cause readmissions, stroke-specific readmissions, or mortality. Conclusions In this pragmatic trial of patients with complex minor stroke/transient ischemic attack, there was no difference in the risk of readmission or mortality with COMPASS-TC relative to UC. Our study could not conclusively determine the reason for the lack of effectiveness of the INV. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02588664.
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Affiliation(s)
| | - Anna M Kucharska-Newton
- Department of Epidemiology College of Public Health University of Kentucky Lexington KY.,Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | - Sara B Jones
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | - Matthew A Psioda
- Department of Biostatistics Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | - Anna M Johnson
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | | | - Jacqueline R Halladay
- Department of Family Medicine University of North Carolina School of Medicine Chapel Hill NC
| | | | - Janet K Freburger
- Department of Physical Therapy School of Health and Rehabilitation Sciences University of Pittsburgh PA
| | - Sabina B Gesell
- Division of Public Health Sciences Department of Social Sciences and Health Policy Wake Forest School of Medicine Winston-Salem NC
| | - Sylvia W Coleman
- Department of Neurology Wake Forest Baptist Health Winston-Salem NC
| | - Mysha E Sissine
- Department of Neurology Wake Forest Baptist Health Winston-Salem NC
| | - Fang Wen
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | - Gary P Hunt
- Cecil G Sheps Center for Health Services Research University of North Carolina at Chapel Hill NC
| | - Wayne D Rosamond
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | - Pamela W Duncan
- Department of Neurology Wake Forest Baptist Health Winston-Salem NC
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9
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Psioda MA, Jones SB, Xenakis JG, D’Agostino RB. Methodological Challenges and Statistical Approaches in the COMprehensive Post-Acute Stroke Services Study. Med Care 2021; 59:S355-S363. [PMID: 34228017 PMCID: PMC8263146 DOI: 10.1097/mlr.0000000000001580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The COMprehensive Post-Acute Stroke Services study was a cluster-randomized pragmatic trial designed to evaluate a comprehensive care transitions model versus usual care. The data collected during this trial were complex and analysis methodology was required that could simultaneously account for the cluster-randomized design, missing patient-level covariates, outcome nonresponse, and substantial nonadherence to the intervention. OBJECTIVE The objective of this study was to discuss an array of complementary statistical methods to evaluate treatment effectiveness that appropriately addressed the challenges presented by the complex data arising from this pragmatic trial. METHODS We utilized multiple imputation combined with inverse probability weighting to account for missing covariate and outcome data in the estimation of intention-to-treat effects (ITT). The ITT estimand reflects the effectiveness of assignment to the COMprehensive Post-Acute Stroke Services intervention compared with usual care (ie, it does not take into account intervention adherence). Per-protocol analyses provide complementary information about the effect of treatment, and therefore are relevant for patients to inform their decision-making. We describe estimation of the complier average causal effect using an instrumental variables approach through 2-stage least squares estimation. For all preplanned analyses, we also discuss additional sensitivity analyses. DISCUSSION Pragmatic trials are well suited to inform clinical practice. Care should be taken to proactively identify the appropriate balance between control and pragmatism in trial design. Valid estimation of ITT and per-protocol effects in the presence of complex data requires application of appropriate statistical methods and concerted efforts to ensure high-quality data are collected.
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Affiliation(s)
- Matthew A. Psioda
- Department of Biostatistics, Collaborative Studies Coordinating Center
| | - Sara B. Jones
- Department of Epidemiology, Gillings School of Global Public Health
| | - James G. Xenakis
- Department of Genetics, University of North Carolina, Chapel Hill
| | - Ralph B. D’Agostino
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
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10
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Hou Y, Bushnell CD, Duncan PW, Kucharska-Newton AM, Halladay JR, Freburger JK, Trogdon JG. Hospital to Home Transition for Patients With Stroke Under Bundled Payments. Arch Phys Med Rehabil 2021; 102:1658-1664. [PMID: 33811853 PMCID: PMC10152978 DOI: 10.1016/j.apmr.2021.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 02/19/2021] [Accepted: 03/02/2021] [Indexed: 11/29/2022]
Abstract
Bundled payments are a promising alternative payment model for reducing costs and improving the coordination of postacute stroke care, yet there is limited evidence supporting the effectiveness of bundled payments for stroke. This may be due to the lack of effective strategies to address the complex needs of stroke survivors. In this article, we describe COMprehensive Post-Acute Stroke Services (COMPASS), a comprehensive transitional care intervention focused on discharge from the acute care setting to home. COMPASS may serve as a potential care redesign strategy under bundled payments for stroke, such as the Centers for Medicare & Medicaid Innovation Bundled Payment for Care Improvement Initiative. The COMPASS care model is aligned with the incentive structures and essential components of bundled payments in terms of care coordination, patient assessment, patient and family involvement, and continuity of care. Ongoing evaluation will inform the design of incorporating COMPASS-like transitional care interventions into a stroke bundle.
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Affiliation(s)
- Yucheng Hou
- Department of Health Policy and Management, Gillings School of Global Public Health, the University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Cheryl D Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, NC
| | - Pamela W Duncan
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, NC
| | - Anna M Kucharska-Newton
- Department of Epidemiology, Gillings School of Global Public Health, the University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY
| | - Jacqueline R Halladay
- Department of Family Medicine, UNC School of Medicine, the University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Janet K Freburger
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, the University of North Carolina at Chapel Hill, Chapel Hill, NC
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11
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Duncan PW, Bushnell C, Sissine M, Coleman S, Lutz BJ, Johnson AM, Radman M, Pvru Bettger J, Zorowitz RD, Stein J. Comprehensive Stroke Care and Outcomes: Time for a Paradigm Shift. Stroke 2020; 52:385-393. [PMID: 33349012 DOI: 10.1161/strokeaha.120.029678] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Worldwide, stroke is prevalent, costly, and disabling in >80 million survivors. The burden of stroke is increasing despite incredible progress and advancements in evidence-based acute care therapies and despite the substantial changes being made in acute care stroke systems, processes, and quality metrics. Although there has been increased global emphasis on the importance of postacute stroke care, stroke system changes have not expanded to include postacute care and outcome follow-up. Our objectives are to describe the gaps and challenges in postacute stroke care and suboptimal stroke outcomes; to report on stroke survivors' and caregivers' perceptions of current postacute stroke care and their call for improvements in follow-up services for recovery and secondary prevention; and, ultimately, to make the case that a paradigm shift is needed in the definition of comprehensive stroke care and the designation of Comprehensive Stroke Center. Three recommendations are made for a paradigm shift in comprehensive stroke care: (1) criteria should be established for designation of rehabilitation readiness for Comprehensive Stroke Centers, (2) The American Heart Association/American Stroke Association implement an expanded Get With The Guidelines-Stroke program and criteria for comprehensive stroke centers to be inclusive of rehabilitation readiness and measure outcomes at 90 days, and (3) a public health campaign should be launched to offer hopeful and actionable messaging for secondary prevention and recovery of function and health. Now is the time to honor the patients' and caregivers' strongest ask: better access and improved secondary prevention, stroke rehabilitation, and personalized care.
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Affiliation(s)
- Pamela W Duncan
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC (P.W.D., C.B., M.S., S.C., M.R.)
| | - Cheryl Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC (P.W.D., C.B., M.S., S.C., M.R.)
| | - Mysha Sissine
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC (P.W.D., C.B., M.S., S.C., M.R.)
| | - Sylvia Coleman
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC (P.W.D., C.B., M.S., S.C., M.R.)
| | - Barbara J Lutz
- School of Nursing, University of North Carolina at Wilmington (B.J.L.)
| | - Anna M Johnson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (A.M.J.)
| | - Meghan Radman
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC (P.W.D., C.B., M.S., S.C., M.R.)
| | | | - Richard D Zorowitz
- Department of Rehabilitation Medicine, MedStar National Rehabilitation Network and Georgetown University School of Medicine, Washington, DC (R.D.Z.)
| | - Joel Stein
- Department of Rehabilitation Medicine, Cornell University, Weill Cornell Medical College, New York, NY (J.S.)
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12
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Kim Y, Glance LG, Holloway RG, Li Y. Medicare Shared Savings Program and readmission rate among patients with ischemic stroke. Neurology 2020; 95:e1071-e1079. [PMID: 32554774 DOI: 10.1212/wnl.0000000000010080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 02/27/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Hospitals participating in the Medicare Shared Savings Program (MSSP) share with the Centers for Medicare and Medicaid Services (CMS) the savings generated by reduced cost of care. Our aim was to determine whether MSSP is associated with changes in readmissions and mortality for Medicare patients hospitalized with ischemic stroke, and whether MSSP has a different impact on safety net hospitals (SNHs) compared to non-SNHs. METHODS This study was based on the CMS Hospital Compare data for risk-standardized 30-day readmission and mortality rates for Medicare patients hospitalized with ischemic strokes between 2010 and 2017. With a propensity score-matched sample, hospital-level difference-in-difference analysis was used to determine whether MSSP was associated with changes in hospital readmission and mortality as well as to examine the impact of MSSP on SNHs compared to non-SNHs. RESULTS MSSP-participating hospitals had slightly greater reductions in readmission rates compared to matched nonparticipating hospitals (difference, 0.25 percentage points; 95% confidence interval [CI], -0.42 to -0.08). Mortality rates decreased among all hospitals, but mortality reduction was not significantly different between MSSP-participating hospitals and matched hospitals (difference, 0.06 percentage points; 95% CI, -0.28 to 0.17). Prior to MSSP, readmission rates in SNHs were higher compared to non-SNHs, but MSSP did not have significantly different impact on hospital readmission and mortality rates for SNHs and non-SNHs. CONCLUSION MSSP led to slightly fewer readmissions without increases in mortality for Medicare patients hospitalized with ischemic stroke. Similar reductions in readmission rates were observed in SNHs and non-SNHs participating in MSSP, indicating persistent gaps between SNHs and non-SNHs.
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Affiliation(s)
- Yeunkyung Kim
- From the Department of Public Health Sciences, Division of Health Policy and Outcomes Research (Y.K., L.G.G., Y.L.), Department of Anesthesiology (L.G.G.), and Department of Neurology (R.G.H.), University of Rochester Medical Center, NY.
| | - Laurent G Glance
- From the Department of Public Health Sciences, Division of Health Policy and Outcomes Research (Y.K., L.G.G., Y.L.), Department of Anesthesiology (L.G.G.), and Department of Neurology (R.G.H.), University of Rochester Medical Center, NY
| | - Robert G Holloway
- From the Department of Public Health Sciences, Division of Health Policy and Outcomes Research (Y.K., L.G.G., Y.L.), Department of Anesthesiology (L.G.G.), and Department of Neurology (R.G.H.), University of Rochester Medical Center, NY
| | - Yue Li
- From the Department of Public Health Sciences, Division of Health Policy and Outcomes Research (Y.K., L.G.G., Y.L.), Department of Anesthesiology (L.G.G.), and Department of Neurology (R.G.H.), University of Rochester Medical Center, NY
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13
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Lutz BJ, Reimold AE, Coleman SW, Guzik AK, Russell LP, Radman MD, Johnson AM, Duncan PW, Bushnell CD, Rosamond WD, Gesell SB. Implementation of a Transitional Care Model for Stroke: Perspectives From Frontline Clinicians, Administrators, and COMPASS-TC Implementation Staff. THE GERONTOLOGIST 2020; 60:1071-1084. [PMID: 32275060 PMCID: PMC7427484 DOI: 10.1093/geront/gnaa029] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Stroke is a chronic, complex condition that disproportionally affects older adults. Health systems are evaluating innovative transitional care (TC) models to improve outcomes in these patients. The Comprehensive Post-Acute Stroke Services (COMPASS) Study, a large cluster-randomized pragmatic trial, tested a TC model for patients with stroke or transient ischemic attack discharged home from the hospital. The implementation of COMPASS-TC in complex real-world settings was evaluated to identify successes and challenges with integration into the clinical workflow. RESEARCH DESIGN AND METHODS We conducted a concurrent process evaluation of COMPASS-TC implementation during the first year of the trial. Qualitative data were collected from 4 sources across 19 intervention hospitals. We analyzed transcripts from 43 conference calls with hospital clinicians, individual and group interviews with leaders and clinicians from 9 hospitals, and 2 interviews with the COMPASS-TC Director of Implementation using iterative thematic analysis. Themes were compared to the domains of the RE-AIM framework. RESULTS Organizational, individual, and community factors related to Reach, Adoption, and Implementation were identified. Organizational readiness was an additional key factor to successful implementation, in that hospitals that were not "organizationally ready" had more difficulty addressing implementation challenges. DISCUSSION AND IMPLICATIONS Multifaceted TC models are challenging to implement. Facilitators of implementation were organizational commitment and capacity, prioritizing implementation of innovative delivery models to provide comprehensive care, being able to address challenges quickly, implementing systems for tracking patients throughout the intervention, providing clinicians with autonomy and support to address challenges, and adequately resourcing the intervention. CLINICAL TRIAL REGISTRATION NCT02588664.
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Affiliation(s)
- Barbara J Lutz
- School of Nursing, University of North Carolina at Wilmington
| | | | - Sylvia W Coleman
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Amy K Guzik
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Laurie P Russell
- Division of Public Health Sciences, Wake Forest University Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Meghan D Radman
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Anna M Johnson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Pamela W Duncan
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Cheryl D Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Wayne D Rosamond
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Sabina B Gesell
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
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14
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Duncan PW, Bushnell CD, Jones SB, Psioda MA, Gesell SB, D'Agostino RB, Sissine ME, Coleman SW, Johnson AM, Barton-Percival BF, Prvu-Bettger J, Calhoun AG, Cummings DM, Freburger JK, Halladay JR, Kucharska-Newton AM, Lundy-Lamm G, Lutz BJ, Mettam LH, Pastva AM, Xenakis JG, Ambrosius WT, Radman MD, Vetter B, Rosamond WD. Randomized Pragmatic Trial of Stroke Transitional Care: The COMPASS Study. Circ Cardiovasc Qual Outcomes 2020; 13:e006285. [PMID: 32475159 DOI: 10.1161/circoutcomes.119.006285] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The objectives of this study were to develop and test in real-world clinical practice the effectiveness of a comprehensive postacute stroke transitional care (TC) management program. Methods and Results The COMPASS study (Comprehensive Post-Acute Stroke Services) was a pragmatic cluster-randomized trial where the hospital was the unit of randomization. The intervention (COMPASS-TC) was initiated at 20 hospitals, and 20 hospitals provided their usual care. Hospital staff enrolled 6024 adult stroke and transient ischemic attack patients discharged home between 2016 and 2018. COMPASS-TC was patient-centered and assessed social and functional determinates of health to inform individualized care plans. Ninety-day outcomes were evaluated by blinded telephone interviewers. The primary outcome was functional status (Stroke Impact Scale-16); secondary outcomes were mortality, disability, medication adherence, depression, cognition, self-rated health, fatigue, care satisfaction, home blood pressure monitoring, and falls. The primary analysis was intention to treat. Of intervention hospitals, 58% had uninterrupted intervention delivery. Thirty-five percent of patients at intervention hospitals attended a COMPASS clinic visit. The primary outcome was measured for 59% of patients and was not significantly influenced by the intervention. Mean Stroke Impact Scale-16 (±SD) was 80.6±21.1 in TC versus 79.9±21.4 in usual care. Home blood pressure monitoring was self-reported by 72% of intervention patients versus 64% of usual care patients (adjusted odds ratio, 1.43 [95% CI, 1.21-1.70]). No other secondary outcomes differed. Conclusions Although designed according to the best available evidence with input from various stakeholders and consistent with Centers for Medicare and Medicaid Services TC policies, the COMPASS model of TC was not consistently incorporated into real-world health care. We found no significant effect of the intervention on functional status at 90 days post-discharge. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02588664.
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Affiliation(s)
- Pamela W Duncan
- Department of Neurology (P.W.D., C.D.B., M.E.S., S.W.C., M.D.R.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Cheryl D Bushnell
- Department of Neurology (P.W.D., C.D.B., M.E.S., S.W.C., M.D.R.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Sara B Jones
- Department of Epidemiology, Gillings School of Global Public Health (S.B.J., A.M.J., A.M.K.-N., L.H.M., W.D.R.), University of North Carolina at Chapel Hill
| | - Matthew A Psioda
- Department of Biostatistics, Collaborative Studies Coordinating Center (M.A.P.), University of North Carolina at Chapel Hill
| | - Sabina B Gesell
- Social Sciences and Health Policy, Division of Public Health Sciences (S.B.G.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Ralph B D'Agostino
- Division of Public Health Sciences, Department of Biostatistics and Data Science (R.B.D., W.T.A.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Mysha E Sissine
- Department of Neurology (P.W.D., C.D.B., M.E.S., S.W.C., M.D.R.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Sylvia W Coleman
- Department of Neurology (P.W.D., C.D.B., M.E.S., S.W.C., M.D.R.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Anna M Johnson
- Department of Epidemiology, Gillings School of Global Public Health (S.B.J., A.M.J., A.M.K.-N., L.H.M., W.D.R.), University of North Carolina at Chapel Hill
| | | | | | - Adrienne G Calhoun
- Area Agency on Aging, Piedmont Triad Regional Council, Kernersville, NC (B.F.B.-P., A.G.C.)
| | - Doyle M Cummings
- Brody School of Medicine, East Carolina University, Greenville, NC (D.M.C.)
| | - Janet K Freburger
- Department of Physical Therapy School of Health and Rehabilitation Science, University of Pittsburgh, PA (J.K.F.)
| | - Jacqueline R Halladay
- Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill (J.R.H.)
| | - Anna M Kucharska-Newton
- Department of Epidemiology, Gillings School of Global Public Health (S.B.J., A.M.J., A.M.K.-N., L.H.M., W.D.R.), University of North Carolina at Chapel Hill
| | | | - Barbara J Lutz
- University of North Carolina at Wilmington School of Nursing (B.J.L.)
| | - Laurie H Mettam
- Department of Epidemiology, Gillings School of Global Public Health (S.B.J., A.M.J., A.M.K.-N., L.H.M., W.D.R.), University of North Carolina at Chapel Hill
| | - Amy M Pastva
- Duke University School of Medicine, Durham, NC (J.P.-B., A.M.P.)
| | - James G Xenakis
- Department of Biostatistics, Gillings School of Global Public Health (J.G.X.), University of North Carolina at Chapel Hill
| | - Walter T Ambrosius
- Division of Public Health Sciences, Department of Biostatistics and Data Science (R.B.D., W.T.A.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Meghan D Radman
- Department of Neurology (P.W.D., C.D.B., M.E.S., S.W.C., M.D.R.), Wake Forest School of Medicine, Winston-Salem, NC
| | | | - Wayne D Rosamond
- Department of Epidemiology, Gillings School of Global Public Health (S.B.J., A.M.J., A.M.K.-N., L.H.M., W.D.R.), University of North Carolina at Chapel Hill
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15
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Gesell SB, Bushnell CD, Jones SB, Coleman SW, Levy SM, Xenakis JG, Lutz BJ, Bettger JP, Freburger J, Halladay JR, Johnson AM, Kucharska-Newton AM, Mettam LH, Pastva AM, Psioda MA, Radman MD, Rosamond WD, Sissine ME, Halls J, Duncan PW. Implementation of a billable transitional care model for stroke patients: the COMPASS study. BMC Health Serv Res 2019; 19:978. [PMID: 31856808 PMCID: PMC6923985 DOI: 10.1186/s12913-019-4771-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/22/2019] [Indexed: 11/16/2022] Open
Abstract
Background The COMprehensive Post-Acute Stroke Services (COMPASS) pragmatic trial compared the effectiveness of comprehensive transitional care (COMPASS-TC) versus usual care among stroke and transient ischemic attack (TIA) patients discharged home from North Carolina hospitals. We evaluated implementation of COMPASS-TC in 20 hospitals randomized to the intervention using the RE-AIM framework. Methods We evaluated hospital-level Adoption of COMPASS-TC; patient Reach (meeting transitional care management requirements of timely telephone and face-to-face follow-up); Implementation using hospital quality measures (concurrent enrollment, two-day telephone follow-up, 14-day clinic visit scheduling); and hospital-level sustainability (Maintenance). Effectiveness compared 90-day physical function (Stroke Impact Scale-16), between patients receiving COMPASS-TC versus not. Associations between hospital and patient characteristics with Implementation and Reach measures were estimated with mixed logistic regression models. Results Adoption: Of 95 eligible hospitals, 41 (43%) participated in the trial. Of the 20 hospitals randomized to the intervention, 19 (95%) initiated COMPASS-TC. Reach: A total of 24% (656/2751) of patients enrolled received a billable TC intervention, ranging from 6 to 66% across hospitals. Implementation: Of eligible patients enrolled, 75.9% received two-day calls (or two attempts) and 77.5% were scheduled/offered clinic visits. Most completed visits (78% of 975) occurred within 14 days. Effectiveness: Physical function was better among patients who attended a 14-day visit versus those who did not (adjusted mean difference: 3.84, 95% CI 1.42–6.27, p = 0.002). Maintenance: Of the 19 adopting hospitals, 14 (74%) sustained COMPASS-TC. Conclusions COMPASS-TC implementation varied widely. The greatest challenge was reaching patients because of system difficulties maintaining consistent delivery of follow-up visits and patient preferences to pursue alternate post-acute care. Receiving COMPASS-TC was associated with better functional status. Trial registration ClinicalTrials.gov number: NCT02588664. Registered 28 October 2015.
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Affiliation(s)
- Sabina B Gesell
- Department of Social Sciences and Health Policy, Department of Implementation Science, Wake Forest School of Medicine, One Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
| | - Cheryl D Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Sara B Jones
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Sylvia W Coleman
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Samantha M Levy
- Department of Biostatistics, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - James G Xenakis
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Barbara J Lutz
- University of North Carolina at Wilmington, School of Nursing, Wilmington, NC, USA
| | | | - Janet Freburger
- University of Pittsburgh, School of Health and Rehabilitation Sciences, Pittsburgh, PA, USA
| | - Jacqueline R Halladay
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anna M Johnson
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Anna M Kucharska-Newton
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA.,Department of Epidemiology, University of Kentucky, College of Public Health, Lexington, KY, USA
| | - Laurie H Mettam
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Amy M Pastva
- Duke University, School of Medicine, Durham, NC, USA
| | - Matthew A Psioda
- Department of Biostatistics, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Meghan D Radman
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Wayne D Rosamond
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Mysha E Sissine
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Joanne Halls
- Department of Earth and Ocean Sciences, University of North Carolina at Wilmington, Wilmington, NC, USA
| | - Pamela W Duncan
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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